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Patient and Family Advisory Council (PFAC) Membership Application

PFAC Membership Application

Name*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email
Date of Birth
MM slash DD slash YYYY
I am a (please check one):
- Patient
- Family member of a patient
- Caregiver of a patient
Diagnosis (If family, please enter your loved one's diagnosis)
Within the past year, what Siteman Cancer Center (SCC) services have you used? (check all that apply)
In the past year, what other services at the Siteman Cancer Center have you utilized? (check all that apply)
Have you ever been a cancer patient or family member of a cancer patient at another hospital or cancer center?
- Yes
- No
If yes, where?
How did you hear about the Siteman PFAC?
Are you able to commit to attend a 2 hour PFAC meeting on a weekday evening once per month?
- Yes
- No
Are you able to commit to joining other SCC work groups held at various dates and times (about 2 – 4 more hours a month?)
- Yes
- No

Members of the Siteman Cancer Center PFAC are hospital volunteers. If selected, you will need to: 1) complete a volunteer application; 2) attend a new volunteer orientation meeting; 3) pass a criminal background check; 4) have a two-step tuberculosis (TB) skin test; 5) have a hospital name badge made; 6) and sign a volunteer agreement form. During the flu season, members of the Siteman Cancer Center PFAC will also need to receive a seasonal flu vaccine and a H1N1 flu vaccine (provided at Barnes-Jewish Hospital free of charge).

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$5.3 million grant supports research into lung cancer recurrence

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Patient and Family Advisory Council (PFAC) Membership Application

PFAC Membership Application